Building political commitment in Peru for TB control through expansion of the DOTS strategy
Cesar Bonillaa, Jaime Bayonab
In the context of public health, Peru has a long history in the fight against TB.1,2 In 1990, the National TB Control Program became a national health priority, receiving government support to establish a programme that has been a model of efficiency at the global level.1 Maintaining TB’s status as national health priority requires a significant level of political commitment, as the base paper noted.3,4
However, in a country like Peru where the health situation is closely related to constant change and rapid social transformation, an important element in ensuring political commitment is positioning the National TB Control Program as the key player in TB management. This effort’s basic principles must be communicated to administrative, political and financial decision-makers.
Political commitment for TB control must be sustained despite changing heads of government and fluctuating political trends. An important element in ensuring political commitment lies in the participation of civil society and TB patient organizations in all levels of TB control activities, including human rights issues.4
When national priorities shift and attention is deflected, TB control efforts can suffer.3 This is exemplified by the negative impacts that resulted from health sector reform efforts early in the current decade.5 Until approximately 2001, Peru was on the path to exceeding its Millennium Development Goals regarding TB control. In 2001–2003, the health reform process caused deterioration in TB case-detection activities.5 Since 2004, this trend has been reversed, yet we must now redouble our efforts to achieve the Millennium Development Goals.
We agree with the lead article’s comments relating to maintaining quality of services, and the Peruvian experience shows that expansion of the DOTS strategy has also allowed us to successfully identify and intervene in high vulnerability areas with elevated risk of tuberculosis transmission. These areas include the prison population, the marginalized urban population in extreme poverty, indigenous populations, those with MDR-TB and others co-infected with HIV.
In 2004, the National TB Control Program was strengthened by four functional pillars: coordination, management, communication and cooperation. These entities all share the responsibilities of management, leadership and accountability. To further ensure political commitment, a technical committee (from government offices of finance and logistics) and an advisory committee (NGOs, technical and financial institutions, scientific and academic institutions) were set up as essential parts of the National TB Control Program. This type of partnership has been crucial in securing political commitment, as civil society and the Ministry of Health have joined efforts to work as a team by sharing leadership and responsibility and integrating activities under a new organizational culture.
These political commitments come not only from the Ministry of Health, but also from other ministries such as Justice, Internal Affairs, Education and others. Such commitments are in the process of being transferred to regional and local levels. The partnership plays an essential role in maintaining political commitment when leaders change and when health services are decentralized.
Finally, the political commitment gained in Peru can be seen in national budget priorities. In the past 15 years, the average budget allocated to the National TB Control Program was US$ 3 million per year. In 2006, this was raised to almost US$ 10 million, representing substantial political commitment.5 ■
- Health, a key to prosperity: successful stories in developing countries. Geneva: WHO; 2002 (WHO/CDS/2004.4).
- Global tuberculosis control: surveillance, planning, and financing. Geneva: WHO; 2002 (WHO/CDS/TB/2002.295).
- P Nunn, et al. The research agenda for improving health policy systems performance and service delivery for tuberculosis control: a WHO perspective. Bull World Health Organ 2002; 80: 471-6.
- TB Stop. Partnership. The Global Plan to Stop TB, 2006-2015. Actions for life: towards a world free of tuberculosis. Int J Tuberc Lun Dis. 2006; 10: 240-1.
- Construyendo alianzas estratégicas para detener la Tuberculosis: La experiencia peruana. Lima: Ministerio de Salud, Dirección General de Salud de las Personas; 2006.
- National TB Program, Lima, Peru.
- Socios En Salud Sucursal PERU, Lima, Peru.